Social Anxiety Disorder (SAD), also called Social Phobia, is an Anxiety Disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. People with SAD have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions.

Individuals with SAD typically become intensely anxious, with increased heart rate, sweating, and other signs of nervous arousal during a social encounter. They may experience symptoms resembling a panic attack. These physical symptoms may cause additional anxiety, often leading to a habitual fear response that reinforces the anxiety of public situations.

SAD is considered a disorder if it is severe enough to adversely affect social or occupational functioning. Although it is common for many people to experience some anxiety before or during a public appearance, anxiety levels in people with SAD can become so high that they begin to avoid social situations. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with SAD recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. People with SAD often suffer “anticipatory” anxiety — the fear of a situation before it even happens — for days or weeks before the event. In addition, they often experience low self-esteem and depression.

SAD can be limited to only one type of situation — such as a fear of speaking in formal or informal situations, or eating or drinking in front of others — or, in its most severe form, a person experiences symptoms whenever they are around other people.

What are the diagnostic criteria for SAD?

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a publication of the American Psychiatric Association, is the standard psychiatric diagnostic reference in the United States and much of the world. It lists the diagnostic criteria for SAD in section 300.23 (please note that references to children have been removed): (1)

A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.

C. The person recognizes that the fear is excessive or unreasonable.

D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s dsease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

Specify if: Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)

For some people, almost any social circumstance is a cause for fear and anxiety. These individuals are said to have Generalized SAD. People for whom just one or two situations produce anxiety are considered to have the Nongeneralized form of the disorder.

A number of researchers have suggested that another way to group people with SAD is based on the kind of situation that evokes dread. Two primary categories or groups are performance and interactional. (2)

The performance grouping includes people who have strong anxiety at the idea of doing something in front of, or in the presence of, other people. Such situations include dining out, working, giving a speech or using a public restroom.

The interactional grouping includes people whose fears center on circumstances where they have to converse or otherwise engage with others, such as meeting new people.

SAD is many times confused with panic disorder. People with SAD typically do not experience panic attacks, in which the principal fear is of having a medical problem (e.g., heart attack). People with SAD realize that it is anxiety and fear that they are experiencing, not a medical problem. They tend not to go to hospital emergency rooms after an anxiety problem. People with Panic Disorder many times go to hospital emergency rooms, because they feel there is something medically and physically wrong with them. (3)

What is the prevalence of SAD?

Between 5 and 13 percent of the adult American public suffer from SAD — 15 to 40 million people. (4) It is difficult to say exactly how many people have SAD, since studies have use a variety of definitions for the disorder. The National Institute of Mental Health says that it affects about 5 percent, or 15 million people. (5) The prevalence of SAD appears to be increasing among white, married, and well-educated individuals. (6)

Women are twice as likely to develop the SAD as men. (7) However, men are more likely to seek treatment. (8)

According to the US National Comorbidity Survey, SAD is the third most common psychiatric disorder in the United States after depression and alcohol dependence. (9)

SAD usually begins in early adolescence (ie, age 11-12 years) but may appear in younger children or older adults. Untreated childhood SAD typically continues into adulthood. (10)

Mental health professionals report that many people suffer quietly for years, looking for help only when their fears have precipitated a major life crisis. (11) Almost 36 percent of people with the disorder report experiencing symptoms for 10 or more years before seeking help. (12)

What is the difference between shyness and SAD?

Although SAD is often thought of as shyness, the two are not the same. The difference lies in the severe effects SAD can have on everyday functioning. People with SAD are not just a little nervous. Their lives are dictated by the need to either avoid certain situations or endure them with extreme anxiety.

Shy people can be very uneasy around others, but they don’t experience the extreme anxiety in anticipating a social situation, and they usually don’t avoid circumstances that make them feel self-conscious.

People with SAD aren’t necessarily shy at all. They can be completely at ease with people most of the time, but particular situations, such as walking down an aisle in public or making a speech, can give them intense anxiety. SAD disrupts normal life, interfering with career or social relationships. For example, a worker can turn down a job promotion because he can’t give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating.

Can SAD be dangerous?

People with SAD suffer from distorted thinking, including false beliefs about social situations and the negative opinions of others. In addition, it has been found that: (13)

SAD can lower self-esteem and increase the risk of depression and suicide.

In an attempt to reduce anxiety and alleviate depression, people with SAD may use alcohol or other drugs, which can lead to addiction.

About half of people with SAD are thought to experience other psychiatric problems at the same time. (14) People with SAD may also develop other Anxiety Disorders, such as Panic Disorder or Obsessive-Compulsive Disorder. In particular, people with SAD may become so anxious that they may begin to experience genuine panic attacks when in dreaded social situations. As more situational panic attacks occur, people with SAD may take extreme measures to avoid situations in which they fear another panic attack may occur or in which help may not be immediately available. This avoidance, similar to that in many Panic Disorder patients, may eventually develop into Agoraphobia, an inability to go beyond known and safe surroundings because of intense fear and anxiety.

What are the physical symptoms of SAD?

Symptoms of SAD can be both mental and physical. The mental symptoms have been discussed fully above, but may be summarized as being intense anxiety in social situations and the avoidance of social situations. Physical symptoms of SAD include: (15)

Blushing

Profuse sweating

Trembling or shaking

Difficulty talking, speaking very softly or with hesitancy

Nausea

Stomach discomfort

Diarrhea

Confusion

Pounding heart

Muscle tension

What are the triggering situations of SAD?

Every person with SAD is different, and can have their own triggering situations that elevate their anxiety. However, there are some common types of scenarios. People with social anxiety usually experience significant distress in the following situations: (16) (17)

Eating or drinking in front of others

Writing or working in front of others

Being the center of attention

Interacting with people, including dating or going to parties

Asking questions or giving reports in groups

Using public toilets

Talking on the telephone

Being introduced to other people

Being teased or criticized

Being watched or observed while doing something

Having to say something in a formal, public situation

Meeting people in authority (“important people/authority figures”)

Feeling insecure and out of place in social situations (“I don’t know what to say.”)

Meeting other people’s eyes

Swallowing, writing, talking, making phone calls if in public

Most social encounters, particularly with strangers

Making “small talk” at parties

Going around the room in a circle and having to say something

Having the physical symptoms of SAD listed above

What are the causes of SAD?

The causes of SAD are unclear. Like other mental health conditions, SAD likely arises from a complex interaction of biology, personal history, and environment.

Biological

SAD may be related to the imbalance of the serotonin. This was discovered because antidepressant drugs, which change the serotonin balance in the brain, help alleviate the symptoms of SAD. (18) Serotonin is one of several special chemical messengers called neurotransmitters. It helps to move information from nerve cell to nerve cell in the brain as well as regulate mood and emotions. If the neurotransmitters are out of balance, messages cannot get through the brain properly. This can alter the way the brain reacts to stressful situations, leading to anxiety. (19)

Some researchers believe that the adrenal gland may be involved in SAD because the beta blocker propranolol is effective in its treatment. Propranolol works by blocking the hormone epinephrine (also known as adrenaline) in the adrenal gland. (20)

Other researchers believe the brain’s amygdala, which controls the fear response, may be involved. (21) People with an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations. (22)

SAD appears to run in families, thus suggesting a genetic factor. It has been found that first-degree relatives of people with SAD are 3 times more likely to have SAD than others. However, specific genes in humans have not been isolated, though the genes responsible for learned fearfulness has been identified in mice. (23)

Environmental

People with SAD may develop their fear from observing the behavior of others or seeing what happened to someone else as the result of their behavior (such as being laughed at or made fun of). (24) This is a process called observational learning or social modeling. (25)

Further, children who are sheltered or overprotected by their parents may not learn good social skills as part of their normal development. (26) An inhibited temperament in childhood has been linked with the development of SAD in adolescence, as well. (27)

Personal History

Personal history has a definite role in the development of SAD. Though there is a biological component to SAD, it still is a learned response to social situations. Childhood or adolescent experience may increase the risk of developing SAD.

Children and adolescents who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to SAD. Those who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk. It has been found that there is an association between SAD and parents who are more controlling or protective of their children. In addition, other negative events in life, such as family conflict or sexual abuse, may be associated with SAD. (28)

The development of SAD may stem from an embarrassing or humiliating experience at a social event in the past. Meeting new people, giving a speech in public or making an important work presentation may trigger SAD symptoms for the first time. These symptoms usually have their roots in adolescence, however.

Can SAD just go away by itself?

Although it waxes and wanes throughout life, SAD is generally viewed as a chronic condition requiring intervention. (29) Some people can conquer it on their own if they develop the appropriate skills. In most cases, however, professional assistance is recommended. (30)

What is the treatment for SAD?

Fortunately, SAD can be treated successfully by a trained mental health professional. Research has shown that there are two main forms of effective treatment for SAD: short-term psychotherapy called cognitive-behavioral therapy, and certain medications. These treatments may be used alone or in combination.

It is important to understand that treatments for SAD do not work instantly, and that no one treatment plan works well for all patients. Treatment must be tailored to a person’s needs. The therapist and patient should work together to determine which treatment plan will be most effective and to assess whether the plan seems to be on track. Adjustments to the plan are sometimes necessary, since patients respond differently to treatment. Overall, the prospects for long-term recovery for most individuals who seek appropriate professional help are good. (31)

Psychotherapy

Psychotherapy can be used alone or in combination with medications. People treated with psychotherapy have been found to have fared 77 percent better than those treated with medication alone. (32)

Cognitive-behavioral therapy is the only type of therapy that has been shown to be effective in treating SAD. (33) There are two basic approaches that cognitive-behavioral therapy uses in the treatment of SAD:

Gradual desensitization, or exposure therapy: This technique involves gradually exposing the patient to simulated situations that normally cause anxiety in the patient. By mastering the situation without anxiety, the patient is eventually able to tolerate more situations that previously induced anxiety. (34)

Cognitive therapies (also called insight-oriented or cognitive restructuring therapies): These help people change thinking patterns that keep them from overcoming their fears. (35) Individuals with SAD often have significant cognitive distortions related to what other people could be thinking about them that might respond to restructuring. (36) These therapies help people identify their misjudgments and develop more realistic expectations of the likelihood of danger in social situations.

Therapy for SAD may also include Anxiety management training — for example, teaching people such techniques as deep breathing to control their levels of anxiety. (37)

Medications

There are several classes of medications that have proved effective for treating SAD. They are:

Selective serotonin reuptake inhibitors (SSRI’s): SSRI’s are quickly becoming the standard first-line medication for SAD. Paroxetine (Paxil) and sertraline (Zoloft) have been approved by the FDA for the treatment of SAD. (38)

Serotonin/norepinephrine reuptake inhibitors (SNRI’s): Venlafaxine (Effexor) has been approved by the FDA for the treatment of SAD. (39)

Other antidepressants: You doctor or mental health provider may try several different antidepressants to find the one most effective for you and with the fewest unpleasant side effects.

Benzodiazepines: These may reduce the feeling of Anxiety in SAD patients. Although they often work quickly, they can be habit-forming. Because of that, they are usually prescribed only for short-term use. They may also be sedating. Alprazolam (Xanax) and clonazepam (Klonopin) are commonly prescribed formulations. (40)

Beta blockers: These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They’re not recommended for general treatment of SAD. (41)

Other medications: Buspirone, gabapentin, and monoamine oxidase inhibitors (MAOI’s) have shown to be effective in treating SAD in studies. (42)